1. A nurse is preparing to administer a blood transfusion to a client who has anemia. Which
of the following actions should the nurse take first?
check for the type and number of units of blood to administer
2. a nurse is providing teaching to an older adult female client who has stress inconti...
1. A nurse is preparing to administer a blood transfusion to a client who has anemia. Which
of the following actions should the nurse take first?
check for the type and number of units of blood to administer
2. a nurse is providing teaching to an older adult female client who has stress incontinence
and a BMI of 32. Which of the following statements by the client indicates an
understanding of the teaching?
I am dieting to lose weight
3. A nurse is providing instructions to a client who has type 2 diabetes and a new
prescription of metformin. Which of the following statements by the client indicates an
understanding of the teaching?
I should take this medication with a meal
4. a nurse is providing teaching to a client who has chronic kidney disease and a new
prescription for erythropoietin. Which of the following statements by the client indicates
an understanding if the teaching?
i am taking this medication to increase my energy level
5. a nurse is caring for a client who has a prescription for enalapril. The nurse should
identify which of the following findings as an adverse effect of the medication?
orthostatic hypotension
6. a nurse is caring for a client who has hypothyroidism. which of the following
manifestations should the nurse expect?
constipation
7. a charge nurse is instructing a newly licensed nurse about caring for a client who has
MRSA. which of the following statements by the new nurse indicates an understanding of
the teaching?
i will leave assessment equipment in the room to use on this patient
8. a nurse is providing teaching to a client who has irritable bowel syndrome (IBS). which
of the following instructions should the nurse include in the teaching?
increase fiber intake to at least 30 g/day
9. a nurse is caring for a client who has a positive culture for c. diff. which of the following
actions should the nurse take?
implement contact precautions for the client
10. a nurse is caring for a client who has a new diagnosis of hyperthyroidism. which of the
following is the priority assessment finding that the nurse should report to the provider?
BP 170/80
11. a nurse is planning care for a client who is scheduled for a throacentesis. which of the
following interventions should the nurse include in the plan?
encourage the client to take deep breaths after the procedure
12. a nurse is assessing a client who has had a suspected cerebrovascular accident. the nurse
should place the priority on which of the following findings?
dysphagia
, 13. a nurse is reviewing the ABG results of a client who has advanced COPD. which of the
following results should the nurse expect?
PaCO2 56
14. a nurse is providing discharge instructions to a client who has laryngeal cancer and is
receiving radiation treatment. which of the following statements by the client indicates an
understanding of the teaching?
i will avoid direct exposure to the sun
15. a nurse is assessing for compartment syndrome in a client who has a short leg cast. which
of the following findings should the nurse identify as a manifestation of this condition?
pain that increases with passive movement
16. a nurse is providing teaching to a client who has a gastric ulcer a d a new prescription for
omeprazole. the nurse should instruct the client that the medication provides relief by
which of the following actions.
suppressing gastric acid production
17. a nurse is assessing a client who has peripheral arterial disease. which of the following
findings should the nurse expect?
hair loss on the lower legs
18. a nurse is assessing a client following the completion of hemodialysis. which of the
following findings is the nurse's priority to report to the provider?
restlessness
19. a nurse is reviewing the medical record of a client who has osteomyelitis and a
prescription of gentamicin. which of the following findings from the client's medical
record should indicate to the nurse the need to withhold the med?
serum creatinine
20. a nurse is reviewing the medical record of a client who has SLE. which of the following
findings should the nurse expect?
facial butterfly rash
21. a nurse is providing teaching to a client who has a new prescription for psyllium. which
of the following information should the nurse include in the teaching?
drink 240 mL of water after administration
22. a nurse in a provider's office is assessing a client who has migraine headaches and is
taking feverfew to prevent her headaches. the nurse should identify that which of the
following client meds interacts with feverfew?
naproxen
23. a nurse in a provider's office is caring for a client who requests sildenafil to treat erectile
dysfunction. which of the following statements should the nurse make?
you will not be able to use sildenfil if you are taking nitroglycerin
24. a nurse is caring for a client who is receiving TPN. a new bag is not available when the
current infusion is nearly completed. which of the following actions should the nurse
take?
administer dextrose 10% in water until the new bag arrives
25. a nurse is providing discharge teaching to a client who has HF and a new prescription for
a potassium-sparing diuretic. which of the following information should the nurse include
in the teaching?
try to walk at least 3 times per week for exercise
, 26. a nurse is planning care for a client who is postop following a laparotomy and has a
closed-suction drain. which of the following actions should the nurse take to manage the
drain?
compress the drain reservoir after emptying
27. a nurse in an emergency department is admitting a client who reports dyspnea and SOB.
which of the following actions is the priority for the nurse to perform prior to
administering oxygen?
determine if the client has a history of COPD
28. a nurse is obtaining a med history from a client who is scheduled to undergo cataract
surgery. the nurse should recognize that which of the following client meds is a
contraindication for the surgery and notify the provider?
warfarin
29. a nurse is caring for a client following extubation of her endotracheal tube 10 min ago.
which of the following findings should the nurse report to the provider immediately
stridor
30. a nurse is providing dietary teaching to a client who is postop following a thyroidectomy
with removal of the parathyroid glands. the nurse should instruct the client to include
which of the following foods to increase calcium in the diet?
12 almonds
31. a nurse is preparing to assist with the insertion of a nontunneled percutaneous central
venous catheter into a subclavian vein. the nurse should plan to place the client in which
of the following positions?
trendelenburg
32. teaching to client with HTN and new med verapamil. what juice should client avoid?
grapefruit
33. client experiencing anaphylactic reaction, after patent airway, which is priority nursing
intervention?
apply oxygen vi face mask
34. client had nephrostomy tube inserted 12hrs ago. what should the nurse report to the
provider?
client reports back pain
35. teaching to perimenopausal and has hormone replacement therapy. adverse effects to
notify provider?
calf pain, numbness in arms, and intense headache
36. older adult with cancer and a new prescription of opioid analgesic. which info should the
nurse include in teaching?
you should increase your fiber intake to prevent constipation
37. a nurse is providing med teaching to a group with seizure disorders. instruction about
phenytoin?
phenytoin decreases the effectiveness of oral contraceptives
38. a nurse is caring for client with supraventricular tachycardia. which action should nurse
take next?
perform synchronized cardioversion
39. change of shift report with four clients. client with greatest risk of developing infection?
COPD and receiving steroid therapy
40. teach with self administration of heparin?
, use electric razor
41. client having seizure, nurse priority?
turn client on the side
42. Female client with hx of UTI, nurse include in teaching
?
clean perineum front to back
43. cardiac assessment with MI 2 days ago. action after hearing this sound?
listen with client on left side
44. client on bed rest and enoxaparin subcut, actions nurse take?
administer med at the same time each day
45. postop following parathyroidectomy. priority action?
place a trach tray at bedside
46. pt with arterial line, following actions should nurse taking?
place a pressure bag around the flush solution
47. teaching client about a fib and purpose of wearing a holter monitor. info should nurse
include in the teaching?
this device can detect when you have an irregular HR
48. client with DKA, client condition improving?
glucose 272
49. stroke on right hemisphere. nurse expect?
impulsive behavior
50. client who has external fixation device for fracture. instruction for nurse plan of care?
use crutches with rubber tips
51. receiving mechanical ventilation via trach tube. nurse recognizes complications with long
term mechanical ventilation?
stress ulcers
52. teaching about asthma use of metered-dose inhaler. understand teaching?
holding breath for 10 secs after inhaling
53. graves disease, picture with exophthalmos?
big eyes, last picture
54. leg cast and demonstration w/crutches on climbing stairs. identify steps
body weight on crutches, advance unaffected leg onto stair, shift weight from crutch to
unaffected, bring crutches and affected leg up to the stair
55. older adult with fractured wrist following fall. last week i crashed my car bc my vision
suddenly blurry.
check for neuro status
56. peforming dressing change recovering from hemicolectomy. large part of bowel is
protruding, action take first?
call for help
57. older adult about osteoporosis prevention. meds increase risk for developing
osteoporosis?
fludrocortisone
58. client having modified radical mastectomy of right breast. intervention for plan of care?
instruct the client that the drain is removed when there is 25mL of output or less over a 24hr
period
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